BillMo Agent Application form

BillMo Mobile Payment Services Agent Application and Account Agreement.

Please use the below tabs to navigate the form and/or jump from page to page.
This form may take up to 30 minutes to complete.

It will require Sensitive Business and Personal Data for all owners with a 10% or more interest of the business.

Please ensure you have all your business and personal information & identification documents available before starting.

You will also need to have several additional verification documents to support this application.

They are:
- Complete W-9
- Government ID
- Copy of Business License
- Copy of Business Utility Bill
- EFT Form & Agreement
- Picture of Retail Location
This online form has many pages and may be Saved and Continued at a later time or from a different location.

To access this form later or to access this form from another location, use the link we sent to your email address.

Note: This may come in handy as you can save and send it to another business owner to obtain their information.

- File Upload Source
- LeadSource
- Application Type
- Lead Tracking Number
- Application Stage
- Agent Account Type
- Sales Rep Email
- Did a BillMo Sales Rep Visit You?
- Date you received this form
  
  MonthDayYear
- Estimated Close Date
- How Many Locations?
  Tthe number of locations which will offer BillMo services
- How Many Owners of This Business?
  Include Owners with 10% or More Interest.
- Legal Business Name*
  The Official Name used on IRS forms
- DBA Name*
  The Name used on your store front
- Date Business Started
  
  MonthDayYear
- Type of Business Entity
- Federal Tax ID - EIN
  Please Enter EIN number or State Tax ID..or both.
- State Tax ID #
  State ID and/or EIN Must Have a Value
- Business Phone Number*
  Format: (000) 000-0000.
- Business Fax Number
  Format: (000) 000-0000.
- Business E-mail
- Business Website
- Agent Business Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Description of Business
- Hours of Business Operation
  What days and times is your business open?
- Business Time Zone
  What Time Zone Do You Operate In?
- Business - Mortgage / Landlord Contact Type
- Business - Mortgage Company Account Type
- Retail Building Ownership Type
  Do You Own or Lease Your Building Space?
- Lessor Company Name
  Enter only If Leasing or Renting.
- Lessor Full Name
  
  First NameLast Name
- Lessor Phone Number
  Format: (000) 000-0000.

- Owner 1 - Contact Type
- Owner 1 - First Name
- Owner 1 - Middle Name
- Owner 1 - Last Name
- Owner 1 - Percent of Ownership
  Must be 100% or Less. List Other Owners Below.
- Is Owner 1 a Guarantor?
  As Guarantor, A Background Investigation May be Required
- Owner 1 - Home Phone
  Format: (000) 000-0000.
- Owner 1 - Mobile Phone
  Format: (000) 000-0000.
- Owner 1 - Personal Email
- Owner 1 - Date of Birth
  
  MonthDayYear
- Owner 1 - Social Security Number
- Owner 1 - Personal ID Type
  Your proof of identity
- Owner 1 - Government ID Number
  Official Number on identity
- Owner 1 - ID Issued By
  Enter Name of Federal, State or Municipal Authorty.
- Owner 1 - Residential Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Owner 1 Residential Mortgage Contact Type
- Owner 1 -Residential Mortgage Company Account Type
- Owner 1- Residential Ownership Type
- Owner 1 - Landlord or Mortgage Company Name
- Owner 1 - Landlord or Mortgage Contact
  
  First NameLast Name
- Owner 1 - Landlord or Mortgage Phone
  Format: (000) 000-0000.
- Owner 1 - Mortgage or Landlord Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Owner 2 - Contact Type
- Required if Owns 10% or More of Business or is a Guarantor
- Not Required because you selected 1 Owner with 100% Ownership of this Company.
  
  Got to Bank Reference 1
- Owner 2 - First Name
- Owner 2 - Middle Name
- Owner 2 - Last Name
- Owner 2 - Percent of Ownership
  Must be 100% or Less. List Other Owners Below.
- Is Owner 2 a Guarantor?
  As Guarantor, A Background Investigation May be Required
- Owner 2 - Home Phone
  Format: (000) 000-0000.
- Owner 2 - Mobile Phone
  Format: (000) 000-0000.
- Owner 2 - Personal Email
- Owner 2 - Date of Birth
  
  MonthDayYear
- Owner 2 - Social Security Number
- Owner 2 - Personal ID Type
  Your proof of identity
- Owner 2 - Government ID Number
  Official Number on identity
- Owner 2 - ID Issued By
  Enter Name of Federal, State or Municipal Authorty.
- Owner 2 - Residential Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Owner 2 Residential Landlord Contact Type
- Owner 2 - Residential Landlord Account Type
- Owner 2 - Residential Ownership Type
- Owner 2 - Landlord or Mortgage Lender Company Name
- Owner 2 - Landlord or Mortgage Contact
  
  First NameLast Name
- Owner 2 - Landlord or Mortgage Phone
  Format: (000) 000-0000.
- Owner 2 - Mortgage or Landlord Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Owner 3 - Contact Type
- Required if Owns 10% or More of Business or is a Guarantor
- Not Required because you selected Less Than 3 Owners of this Company
  
  Got to Bank Reference 1
- Owner 3 - First Name
- Owner 3 - Middle Name
- Owner 3 - Last Name
- Owner 3 - Percent of Ownership
  Must be 100% or Less. List Other Owners Below.
- Is Owner 3 a Guarantor?
  As Guarantor, A Background Investigation May be Required
- Owner 3 - Home Phone
  Format: (000) 000-0000.
- Owner 3 - Mobile Phone
  Format: (000) 000-0000.
- Owner 3 - Personal Email
- Owner 3 - Date of Birth
  
  MonthDayYear
- Owner 3 - Social Security Number
- Owner 3 - Personal ID Type
  Your proof of identity
- Owner 3 - Government ID Number
  Official Number on identity
- Owner 3 - ID Issued By
  Enter Name of Federal, State or Municipal Authorty.
- Owner 3 - Residential Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Owner 3 - Residential Landlord Contact Type
- Owner 3 - Residential Mortgage Company Account Type
- Owner 3- Residential Ownership Type
- Owner 3 - Landlord or Mortgage Lender Company Name
- Owner 3 - Landlord or Mortgage Contact
  
  First NameLast Name
- Owner 3 - Landlord or Mortgage Phone
  Format: (000) 000-0000.
- Owner 3 - Mortgage or Landlord Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Owner 4 - Contact Type
- Required if Owns 10% or More of Business or is a Guarantor
- Not Required because you selected Less Than 4 Owners of this Company.
  
  Got to Bank Reference 1
- Owner 4 - First Name
- Owner 4 - Middle Name
- Owner 4 - Last Name
- Owner 4 - Percent of Ownership
  Must be 100% or Less. List Other Owners Below.
- Is Owner 4 a Guarantor?
  As Guarantor, A Background Investigation May be Required
- Owner 4 - Home Phone
  Format: (000) 000-0000.
- Owner 4 - Mobile Phone
  Format: (000) 000-0000.
- Owner 4 - Personal Email
- Owner 4 - Date of Birth
  
  MonthDayYear
- Owner 4 - Social Security Number
- Owner 4 - Personal ID Type
  Your proof of identity
- Owner 4 - Government ID Number
  Official Number on identity
- Owner 4 - ID Issued By
  Enter Name of Federal, State or Municipal Authorty.
- Owner 4 - Residential Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Owner 4 - Residential Mortgage Contact Type
- Owner 4 - Residential Mortgage Account Type
- Owner 4- Residential Ownership Type
- Owner 4 - Landlord or Mortgage Lender Company Name
- Owner 4 - Landlord or Mortgage Contact
  
  First NameLast Name
- Owner 4 - Landlord or Mortgage Phone
  Format: (000) 000-0000.
- Owner 4 - Mortgage or Landlord Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Owner 5 - Contact Type
- Required if Owns 10% or More of Business or is a Guarantor
- Not Required because you selected Less Than 5 Owners of this Company.
  
  Got to Bank Reference 1
- Owner 5 - First Name
- Owner 5 - Middle Name
- Owner 5 - Last Name
- Owner 5 - Percent of Ownership
  Must be 100% or Less. List Other Owners Below.
- Is Owner 5 a Guarantor?
  As Guarantor, A Background Investigation May be Required
- Owner 5 - Home Phone
  Format: (000) 000-0000.
- Owner 5 - Mobile Phone
  Format: (000) 000-0000.
- Owner 5 - Personal Email
- Owner 5 - Date of Birth
  
  MonthDayYear
- Owner 5 - Social Security Number
- Owner 5 - Personal ID Type
  Your proof of identity
- Owner 5 - Government ID Number
  Official Number on identity
- Owner 5 - ID Issued By
  Enter Name of Federal, State or Municipal Authorty.
- Owner 5 - Residential Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Owner 5 - Residential Mortgage Contact Type
- Owner 5 - Residential Mortgage Company Account Type
- Owner 5 - Residential Ownership Type
- Owner 5 - Landlord or Mortgage Lender Company Name
- Owner 5 - Landlord or Mortgage Contact
  
  First NameLast Name
- Owner 5 - Landlord or Mortgage Phone
  Format: (000) 000-0000.
- Owner 5 - Mortgage or Landlord Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Bank 1 - Contact Type
- Bank 1 - Account Type
- Bank 1 Name
- Bank 1 Account Number
- Bank 1 Contact
  
  First NameLast Name
- Bank 1 Phone
  Format: (000) 000-0000.
- Bank 1 Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- A 2nd Bank Reference is only required if you will be using the account for BillMo Services.
- Bank 2 - Contact Type
- Bank 2 - Account Type
- Bank 2 Name
- Bank 2 Account Number
- Bank 2 Contact
  
  First NameLast Name
- Bank 2 Phone
  Format: (000) 000-0000.
- Bank 2 Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Trade 1 - Contact Type
- Trade 1 - Account Type
- (List 1 of 2 suppliers other than BillMo LLC that extend credit terms - No COD)
- Trade Reference 1 Company Name
- Trade Reference 1 Contact
  
  First NameLast Name
- Trade Reference 1 Phone
  Format: (000) 000-0000.
- Trade Reference 1 Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Trade 2 - Contact Type
- Trade 2 - Account Type
- (List 2nd supplier other than BillMo LLC that extend credit terms - No COD)
- Trade Reference 2 Company Name
- Trade Reference 2 Contact
  
  First NameLast Name
- Trade Reference 2 Phone
  Format: (000) 000-0000.
- Trade Reference 2 Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry

- Do you currently Offer Money Transfer Services?
- What Services Do You Use?
  Cntrl / Command to Select Multiple
- Other Services Offered
  Or the Name of Xfer Services Not listed
- What Is Your Avg. Transfer Amount?
  Provide Best Estimate if Not Currently Providing Services.
- How Many Transfers per MONTH?
  Provide Best Estimate if Not Currently Providing Services.
- Monthly Opportunity Amount
  Avg Trans Amount x Weekly Amount X 4
- Proposed Settlement Method:
- Nearest Bank Branch for Cash Deposits
  Enter Name of the Nearest Branch To Your Business
- Frequency of Settlement:
  (Hold down CONTROL or SHIFT or COMMAND key for Multiple)

- A) Has the Agent (i.e., the company), the principal owner of the Agent or any guarantor ever declared bankruptcy?
- Bankruptcy Selection
  If Yes, Please Describe Below
- B) Is the Agent (i.e., the company), the principal owner of the Agent or any guarantor currently involved in any litigation or other legal or regulatory proceedings?
- Litigation Selection
  If Yes, Please Describe Below
- C) Has the Agent (i.e., the company), the principal owner of the Agent or any guarantor ever been convicted of a felony or misdemeanor or had a civil judgment entered against them?
- Conviction / Judgement Selection
  If yes, Please Describe Below
- D) Is the Agent (i.e., the company), the principal owner of the Agent or any guarantor engaged in the business of internet gambling?
- Gambling Selection
  If Yes, Please Describe Below
- E) Billmo Payment Services requires each location to have:
  
  Computer, Printer, and Internet Services.
- Do You Have the Required Equipment?
  If Yes, Please Describe Below
- If YES to any of the questions above, Or Do Not have the Required Equipment, please describe below:

- Please Note: Your application can not be processed for approval until BillMo receives all the below documents. In the event that you can't upload the documents now, please be sure to make arrnagements to provide these documents to BillMo at your earliest convenience to avoid delays.
- Government ID for Each Owner
  
  Upload a File
  Click to upload file(s) from your computer Cancelof
- ID Provided Via
  Please Tell Us How You Will Send/Sent
- Complete W-9 Form
  
  Upload a File
  Click to upload file(s) from your computer Cancelof
- W-9 Provided Via
  Please Tell Us How You Will Send/Sent
- Copy of Business License
  
  Upload a File
  Click upload file(s) from your computer Cancelof
- License Provided Via
  Please Tell Us How You Will Send/Sent
- Utility Bill for Locations
  
  Upload a File
  Click to upload file(s) from your computer Cancelof
- Utility Bill Provided Via
  Please Tell Us How You Will Send/Sent
- Picture of Retail Locations
  
  Upload a File
  Click to upload file(s) from your computer Cancelof
- Picture of Location Provided Via
  Please Tell Us How You Will Send/Sent
- Upload a Voided Check
  
  Upload a File
  Click to upload file(s) from your computer Cancelof
- Voided Check Provided Via
  Please Tell Us How You Will Send/Sent
- Please note: Your application can not be processed for approval until BillMo receives all the below documents. In the event that you can't upload the documents now, please be sure to make arrnagements to provide these documents to BillMo at your earliest convenience to avoid delays.

- (Must be signed by Principal Owner of Agent, Any Owner of 10% or more of Agent and Guarantor)
  
  By signing below, I, on behalf of myself (and solely with respect to the Principal Owner of Agent on behalf of the Agent) hereby authorize BillMo LLC and their agents and affiliates (collectively, "BillMo LLC") to make periodic investigative background inquiries concerning me, Agent and Agent’s principals (as applicable), including investigating my business/personal credit, financial, educational, driving, military, prior employment and criminal history records and those of the Agent and its principals and to make inquiries from any and all credit/trade/personal/business sources (including banks, credit card companies, credit reporting agencies, business associates, governmental authorities and any other source who may have knowledge regarding me, Agent or its principals) in connection with this application. I acknowledge that a background investigative consumer report may contain information on my character, general reputation, personal characteristics, or mode of living, all or part of which is obtained through personal interviews with neighbors, friends, associates and acquaintances who may have knowledge concerning any such items of information. I understand that before adverse action can be taken against me in whole or in part due to the results of the above-referenced consumer report or investigative consumer report, such report(s) will be provided to me with a written summary of my rights under the Fair Credit Reporting Act, as amended. I further understand that I may have additional rights under applicable state law. I further understand that under IBillMo LLC procedure, BillMo LLC may terminate any agreement if the results of any background check are not satisfactory to BillMo LLC in its sole discretion. I hereby authorize all corporations, companies, credit agencies, educational and military institutions, persons, law enforcement agencies, criminal civil and federal courts, and governmental agencies to release and forward to BillMo LLC any and all information, references and records sought in connection with any request by BillMo LLC for a reference. I and Agent further authorize BillMo LLC to share the information received from any source with BillMo LLC’s parent entity and affiliates. Upon request BillMo LLC will tell me whether consumer credit reports were requested and, if so, the name and address of the consumer credit reporting agency that furnished the reports. Agent and each of the persons signing below hereby release BillMo LLC and its agents, parent entities, subsidiaries and affiliates from any and all liabilities, claims or suits regarding the investigation, inquiries, consumer reports and information obtained from any and all sources.
- Type Name of Principal Owner 1
  
  First NameLast Name
- Date Signed - Owner 1
  
  MonthDayYear
- E-Signature Of Principal Owner 1
- Type Name of Principal Owner 2
  
  First NameLast Name
- Date Signed - Owner 2
  
  MonthDayYear
- E-Signature Of Principal Owner 2
- Type Name of Principal Owner 3
  
  First NameLast Name
- Date Signed - Owner 3
  
  MonthDayYear
- E-Signature Of Principal Owner 3
- Type Name of Principal Owner 4
  
  First NameLast Name
- Date Signed - Owner 4
  
  MonthDayYear
- E-Signature Of Principal Owner 4
- Type Name of Principal Owner 5
  
  First NameLast Name
- Date Signed - Owner 5
  
  MonthDayYear
- E-Signature Of Principal Owner 5

- Agreement and Signature
  
  By signing below, I and Agent represent to BillMo LLC that (1) I am the principal owner or an authorized representative of Agent and have full authority to sign this Application on behalf of Agent and (2) to the best of my and Agent’s knowledge all of the information contained in this Application is true and correct. By signing below Agent agrees with the terms and conditions contained in this Application and the Money Transfer Agent Agreement as well as all BillMo LLC procedures and policies regarding money transfer and payment services.
- Type Name of Principal Owner or Officer of Agent:
  
  First NameLast Name
- Date Signed:
  
  MonthDayYear
- E-Signature of Principal Owner or Officer of Agent:*
- Denial Notice
  
  Notice: If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact BillMo LLC, 765 Straits Turnpike Middlebury, CT 06762 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act.
- Billmo LLC, New Accounts Department, 765 Straits TurnpikeMiddlebury, CT 06762 Phone: 877 212-7363 Fax: 888 316-6309 Email:agent.support@billmo.com
- Should be Empty:

BillMo Mobile Payment Services Agent Application and Account Agreement.

This form may take up to 30 minutes to complete.

It will require Sensitive Business and Personal Data for all owners with a 10% or more interest of the business.

Please ensure you have all your business and personal information & identification documents available before starting.

You will also need to have several additional verification documents to support this application.

They are: